Form Va-4 - Personal Exemption Worksheet
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1
2FORM VA.4
COMMONWEALTH OF
VI
RGIN
IA
DEPARTMENT OF TAXATION
PERSONAL EXEMPTION WORKSHEET
(See back for instructions)
1.
lf
you wish to claim
yourself,
write
"1"
2
lf
you
arr-5
married and your
spouse
is not claimed
on his or her own certificate,
write
"1"
3.
Write
ther
number of
dependents
you
will
be allowed to claim
on your income
tax
return (do not include your spouse)
4.
Subtotal Personal
Exemptions
(add
lines
1
through
3)
.
5.
Exemptions
for
age
(a)
lf you
will
be
65 or
older
on
January
1,
write
"'1"
(b)
lf you claimed an
exemption
on line 2 and your spouse
lvill
be 65 or older on
January
1,
write
"1"
6
Exempti<lns
for
blindness
(a)
lf you are legally blind,
write
"1"
(b)
lf you claimed an
exemption
on line 2 and your
spouse is legally blind,
write
"1"
7.
Subtotal exemptions for age
and
blindness (add lines
5
through
6).....
..
8.
Total of
E:xemptions
- add line
4
and line
7
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d)
&
s
O
O
N
COMPLETE
THE
APPLICABLE LINES BELOW
1
.
lf subject to
withholding,
enter
the
number of exemptions claimed
on:
(a)
Siubtotal
of
Personal Exemptions
-
line 4 of the
F'ersonal Exemotion Worksheet
(b)
S;ubtotal
of
Exemptions
forAge and
Blindness
line 7 of
the
Personal Exemotion
Worksheet..
(c)
Total Exemptions -
line
8 of
the
Personal Exemption Worksheet
2.
Enter the amount of
additionalwithholding
requested (see
instructions)...............
.
3
|
certify
that
I
am not subject to Virginia
withholding
I
meet the conditions
set forth
in
the
instructions
...........
..
(check
here)
4
|
certify tfrat
I
am not subject to Virginia
withholding.
I
meet the
conditions
set forth
Under
the;
Service member
Civil
Relief
Act,
as amended
by
the
Military Spouses
Residencv Relief
Act
(check
here)
Signature
Date
EMPLOYER: Keep
exemption certificates with your
records
lf
you
believe
the employee
has claimed
too many exemptions,
notify
the Departnrent
of
Taxation,
PO
Box
1115,
Richmond,
Virginia
23218-1115,
telephone (804)
367-8037
Note: Employers may establish
a
system to electronically
receive
Forms VA-4 fronr
employees, provided the system meets Internal Revenue Service requirements
as
specified in
S
31.3402(f)(5)-1(c)
of
lhe
Treasury
Regulations (26
CFR)
FORM
VA-4
EMPLOYEE'S VIRGINIA
INCOME TAX
WITHHOLDING
EXEMPTION CERTIFICATE
Your Social Sr:curity Number
Name
Street Address
Jty
State
Zip
Code
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